DOI: 10.1111/1471-0528.

15153 Systematic review

www.bjog.org

Mindfulness, cognitive behavioural and

behaviour-based therapy for natural and
treatment-induced menopausal symptoms:
a systematic review and meta-analysis
CM van Driel,a,b A Stuursma,a,b MJ Schroevers,c MJ Mourits,a GH de Bockb
a
Department of Obstetrics & Gynaecology, University Medical Centre Groningen, Groningen, the Netherlands b Department of Epidemiology,
University Medical Centre Groningen, Groningen, the Netherlands c Department of Health Psychology, University Medical Centre Groningen,
Groningen, the Netherlands
Correspondence: CM van Driel, Department of Epidemiology, University Medical Centre Groningen, University of Groningen, PO Box 30.001,
9700 RB Groningen, the Netherlands. Email: cmg.driel@umcg.nl

Accepted 26 January 2018. Published Online 15 March 2018.

Background During menopause women experience vasomotor and
psychosexual symptoms that cannot entirely be alleviated with
hormone replacement therapy (HRT). Besides, HRT is
contraindicated after breast cancer.
Objectives To review the evidence on the effectiveness of
psychological interventions in reducing symptoms associated with
menopause in natural or treatment-induced menopausal women.
Search strategy Medline/Pubmed, PsycINFO, EMBASE and
AMED were searched until June 2017.
Selection criteria Randomised controlled trials (RCTs) concerning
natural or treatment-induced menopause, investigating
mindfulness or (cognitive-)behaviour-based therapy were selected.
Main outcomes were frequency of hot flushes, hot flush bother
experienced, other menopausal symptoms and sexual functioning.
Data collection and analysis Study selection and data extraction
were performed by two independent researchers. A meta-analysis
was performed to calculate the standardised mean difference
(SMD).
Main results Twelve RCTs were included. Short-term
(<20 weeks) effects of psychological interventions in comparison
to no treatment or control were observed for hot flush bother
(SMD 0.54, 95% CI 0.74 to 0.35, P < 0.001, I2 = 18%)
and menopausal symptoms (SMD 0.34, 95% CI 0.52 to
0.15, P < 0.001, I2 = 0%). Medium-term (≥20 weeks) effects
were observed for hot flush bother (SMD 0.38, 95% CI
0.58 to 0.18, P < 0.001, I2 = 16%). [Correction added on
9 July 2018, after first online publication: there were
miscalculations of the mean end point scores for hot flush
bother and these have been corrected in the preceding two
sentences.] In the subgroup treatment-induced menopause,
consisting of exclusively breast cancer populations, as well as in
the subgroup natural menopause, hot flush bother was reduced
by psychological interventions. Too few studies reported on
sexual functioning to perform a meta-analysis.
Conclusions Psychological interventions reduced hot flush
bother in the short and medium-term and menopausal
symptoms in the short-term. These results are especially
relevant for breast cancer survivors in whom HRT is
contraindicated. There was a lack of studies reporting on the
influence on sexual functioning.
Keywords Behavioural therapy, cognitive behavioural therapy,
menopause, mindfulness, sexual functioning, vasomotor
symptoms.
Tweetable abstract Systematic review: psychological interventions
reduce bother by hot flushes in the short- and medium-term.

Please cite this paper as: van Driel CM, Stuursma A, Schroevers MJ, Mourits MJ, de Bock GH. Mindfulness, cognitive behavioural and behaviour-based therapy
for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis. BJOG 2019;126:330–339.

Introduction
Menopause can occur either naturally or can be induced by
CMG van Driel and AS Stuursma contributed equally to the manuscript. treatments such as pelvic radiation, oophorectomy, endo-
PROSPERO register number: CRD42016038135. crine therapy or chemotherapy.1,2

330 ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Menopausal symptoms are experienced frequently with
up to 85% of menopausal women reporting vasomotor
symptoms (i.e. hot flushes and night sweats), up to 60%
reporting vaginal discomfort (i.e. vaginal dryness and/or
dyspareunia), and up to 87% reporting sexual dysfunction
(e.g. lack of sexual desire and difficulty reaching orgasm).3–5
Moreover, women who experience treatment-induced
menopause report more severe symptom levels than women
experiencing natural menopause.6,7
To reduce the aforementioned symptoms, hormone
replacement therapy (HRT) is currently the most effective
option.8,9 However, the use of HRT in postmenopausal
women is associated with increased breast cancer risk and
contraindicated in breast cancer survivors.10,11 Further-
more, HRT only partially relieves symptoms, symptom
levels remain higher than in premenopausal women and
especially sexual discomfort is not alleviated.12 Therefore,
safe nonhormonal alternatives to HRT are needed, in par-
ticular for breast cancer survivors such as young BRCA1/2
mutation carriers after breast cancer and risk-reducing
salpingo-oophorectomy.
Nonhormonal options to decrease the frequency and
bother of hot flushes include stress-reducing psychological
interventions such as cognitive behavioural therapy (CBT),
behavioural therapy (BT) and mindfulness-based therapies
(MBT).13 The possible mechanism of action of these inter-
ventions is that they reduce stress. Stress is thought to lower
the threshold for heat dissipation responses14,15 and therefore
can potentiate a hot flush.16 It is proposed that CBT, BT and
MBT diminish this trigger by reducing stress, so reducing the
frequency of hot flushes. An additional mechanism of action
of the above-mentioned interventions might be that by mod-
ifying cognitive appraisals of hot flushes, the bother caused
by hot flushes can be decreased.13
Several large randomised controlled trials (RCTs) that
were recently published have investigated the effect of CBT,
MBT and BT on hot flushes and other menopausal symp-
toms.17–20 The aim of this systematic review and meta-ana-
lysis is to add a quantitative examination of the existing
evidence on the effectiveness of psychological interventions
in reducing symptoms associated with menopause in
women with natural or treatment-induced menopause.
Methods
The conduct and reporting of this systematic literature
review and meta-analysis was based on the Preferred
Reporting Items for Systematic Reviews and Meta-analysis
(PRISMA) statement.21 First, studies were screened for eli-
gibility based on their titles and abstract. Full texts of pos-
sibly eligible studies were retrieved after the initial
screening for more detailed evaluation. Second, two review
authors (CD and AS) independently performed a final
ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Psychological therapy for menopausal symptoms
selection of studies, assessed the risk of bias and extracted
data from the full-text papers using a prespecified form.
The following data were extracted with the use of these
forms: population (e.g. sample size, natural or treatment-
induced menopause), intervention (e.g. type of interven-
tion, duration, length of programme), control group, co-
interventions and outcomes (e.g. frequency and bother of
hot flushes, menopausal symptoms, sexual functioning and
adverse effects). Of the outcomes, the time-points of mea-
surement and results such as means and measure of vari-
ance were extracted.
Menopausal symptoms were defined as the combined
level of burden from a broad range of symptoms related to
menopause such as psychosocial symptoms (e.g. irritability,
forgetfulness), physical symptoms (e.g. joint pain, head-
aches), genital symptoms (e.g. dryness, itching), sexual dys-
function and vasomotor symptoms.
Electronic databases that were searched are Medline/
Pubmed, EMBASE, PsycINFO and AMED. Other search
methods used were reference checking of selected studies and
of existing reviews on adjacent topics. Search terms of the
electronic literature search are provided in the (Table S1).
The initial search was conducted in February 2016 and an
updated search was performed in June 2017.
Risk of bias was assessed with the risk of bias tool from
the Cochrane collaboration,22 see (Table S2). Disagreements
on inclusion of studies, extracted data or risk of bias assess-
ments was solved by consensus between the two review
authors (CD and AS). If consensus was not reached the
other authors were consulted (GB, MS and MM). The pro-
tocol of this systematic literature review and meta-analysis is
registered in the PROSPERO database (CRD42016038135).
Eligibility criteria
Studies considered eligible were RCTs with a published full
text in English evaluating the effect of CBT, BT or MBT on
either naturally occurring or treatment-induced hot flushes,
menopausal symptoms or sexual functioning compared
with a waiting list or with ‘care as usual’ (e.g. lifestyle
advice, breast cancer follow up). Menopause did not have
to be formally established (e.g. by amenorrhea >12 months
or laboratory tests), but could be based on patient-reported
signs and symptoms of menopause. The intervention could
either consist of group or individual therapy and could be
a general programme or could be specifically tailored to
symptoms associated with menopause. Only patient-
reported outcomes were included.
Studies were excluded if interventions were limited to
yoga, hypnosis, exercise, meditation, awareness training or
breathing techniques as a stand-alone therapy, because
these interventions were either not based on a stress-redu-
cing mechanism of action or were not based on widely
used protocolled standards. Studies were also excluded if
331
 van Driel et al.
there was no face-to-face therapeutic contact with a thera-
pist or trainer during the study (e.g. web-based interven-
tions). Use of HRT in the intervention and/or control
group was allowed. However, studies that specifically aimed
to use HRT as the control condition were excluded. Lastly,
studies were excluded if the outcomes were physical mea-
sures (e.g. sternal skin conductance) only. The rationale
behind favouring patient-reported outcomes over physical
measures was that patient-reported hot flush frequency
could be more closely related to actual inconvenience
caused by hot flushes as patient-reported hot flush fre-
quency measures the perceptual aspect, whereas physical
measures assess the physiological aspect of the hot flush
construct.23 Therefore we deemed patient-reported out-
comes to be of more interest for clinical practice.
Statistical analysis
The following outcomes were considered at short-term
(<20 weeks after randomisation) and at medium-term
(≥20 weeks after randomisation): frequency and bother of
hot flushes, menopausal symptoms and sexual functioning.
A random effects meta-analysis using inverse variance
method was performed. Using mean end points and stan-
dard deviations (SDs), per study a standardised mean dif-
ference (SMD) with a 95% CI was calculated for all
outcomes. Effect size was defined as small (0.2), medium
(0.5) or large (0.8).24 Heterogeneity was assessed per out-
come with I2, chi-square test and P-value. Funnel plots
were made to assess publication bias. Asymmetrical funnel
plots indicate a higher risk of publication bias.22 Asymme-
try was assessed using Egger’s test, which was interpreted
using a cut-off value of 0.10.25 As the effect of the interven-
tions could differ for treatment-induced and natural meno-
pausal symptoms, a subgroup analysis was performed for
natural menopause versus treatment-induced menopause
when two or more studies were available per subgroup for
an outcome. All analyses were performed using REVIEW
MANAGER (RevMan version 5.3.5.).
Results
Selection of studies
A flow diagram of the study selection is shown in Figure 1.
Based on the title and abstract screening, 24 records were
eligible for full-text assessment, of which 12 records did
not meet the eligibility criteria. So, the final number of
included studies in the qualitative synthesis was 12. Of the
included studies, ten studies could be included in the main
quantitative synthesis (meta-analysis), as two studies only
reported medians because of possible skewness of the
data.26,27 An overview of studies reporting medians com-
pared with studies in the main meta-analysis is shown in
Figure 2.
332 ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Characteristics of included studies
The total size of study population per study varied from 16
to 214 women (Table 1). The combined sample size of all
studies consisting of participants in the control and inter-
vention groups was 1016 women. Six of the 12 included
studies involved women whose symptoms were treatment-
induced, all of which concerned breast cancer sur-
vivors.17,19,26–29 Three studies investigated the effect of
MBT,19,28,30 five studies investigated CBT17,18,29,31,32 and
four studies investigated BT.20,26,27,33 All studies, except
three had a waiting list control group.27,29,33 One study had
a ‘care as usual’ control group,29 which consisted of breast
cancer survivors during follow up with lifestyle advice on
coping with hot flushes by a nurse specialist. The second
study had a population of women experiencing natural
menopause and had an active control group. The placebo
activity in this case was individual leisure reading.33 The
third study was conducted in breast cancer survivors and
had an attention control group. The attention consisted of
a general discussion of menopausal complaints with a
nurse.27
To measure hot flush frequency, the frequency subscale
of the hot flush rating scale (HFRS scale) or similar diaries
were used. Hot flush bother was most often measured by
the HFRS subscale that measures bother by hot flushes
(problem-rating, distress and interference). Menopausal
symptoms were measured using the Functional Assessment
of Cancer Therapy – Endocrine Therapy Scale (FACT-ES)
and the Menopausal Quality of life scale (MENQOL). Both
questionnaires contain psychosocial, physical, vaginal, sex-
ual and vasomotor items. Sexual activity was measured by
the habit subscale of the Sexual Activity Questionnaire
(SAQ) and sexual behaviour subscale of the Women’s
Health Questionnaire (WHQ). An overview of the reported
results of the main outcomes is given in the (Table S3).
Assessment of risk of bias
A high risk of performance bias was present for all studies,
because blinding of CBT-, BT- and MBT-based interven-
tions is not feasible (see Table S4). Consequently, the risk
of detection bias was high because outcomes were patient-
reported.
Meta-analysis of overall effect
A statistically significant benefit from psychological interven-
tions was seen on short-term hot flush bother (SMD 0.54,
95% CI 0.74 to 0.35, P < 0.001), short-term menopausal
symptoms (SMD 0.34, 95% CI 0.52 to 0.15, P < 0.001)
and medium-term hot flush bother (SMD 0.38, 95% CI
0.58 to 0.18, P < 0.001) (Table 2). [Correction added on
9 July 2018, after first online publication: there were miscal-
culations of the mean end point scores for hot flush bother
and these have been corrected in the preceding sentence.] No
Royal College of Obstetricians and Gynaecologists
 Psychological therapy for menopausal symptoms

Records identified through Additional records identified

database searching through other sources
(n = 5725) (n = 0)

Records after removing duplicates

(n = 4077)

Records screened Records excluded

(n = 4077) (n = 4053)

Full-text articles Full-text articles excluded, with

assessed for eligibility reasons:
(n = 24) (n = 12)
- 5 No published full-text
- 1 No English full-text
- 2 Not an RCT
- 2 No CBT, BT, MBT
- 2 Ineligible control group
Studies included in
synthesis
(n = 12)

Studies included in
quantitative synthesis
(meta-analysis)
(n = 10)

Figure 1. Flow diagram of study selection.

statistically significant benefit from psychological interven- Subgroup analysis

tions was seen on short-term hot flush frequency (SMD
0.41, 95% CI 0.83 to 0.01, P = 0.05) or medium-term
hot flush frequency (SMD 0.21, 95% CI 0.89 to 0.26,
P = 0.29). Heterogeneity was high for most outcomes. A
meta-analysis of sexual functioning was not feasible because
only two studies reported on this outcome.17,20 An overview
of the exact data entered into the main meta-analysis is
shown in the (Table S5).
Publication bias
The Egger test result was >0.10 for all studies, indicating
no proof of statistically significant publication bias. How-
ever the funnel plots showed some asymmetry, indicating
that this result could be due to a limited number of studies
per outcome (see Figure S1).
A beneficial effect of psychological interventions was seen
on short-term hot flush bother in the subgroup treatment-
induced menopause (SMD 0.47, 95% CI 0.69 to 0.25,
P < 0.001) as well as in the subgroup natural menopause
(SMD 0.85, 95% CI: 1.11 to 0.59, P < 0.001) (see Fig-
ure S2). Benefit of psychological interventions was also seen
on medium-term hot flush bother for both the natural
menopause subgroup (SMD 0.77, 95% CI 1.16 to
0.39, P < 0.001) as well as in the treatment-induced
menopause subgroup (SMD 0.32, 95% CI 0.64 to 0.00,
P =0.05).
Adverse effects
Four studies reported on adverse effects of CBT, MBT and
BT and did not encounter any adverse effects.18,20,28,29

ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of 333
Royal College of Obstetricians and Gynaecologists
 van Driel et al.

Figure 2. Forrest plot of hot flush frequency, hot flush bother, menopausal symptoms and sexual functioning for both short-term (<20 weeks) and
medium-term (≥20 weeks) results, split for mean and median outcomes. CI, confidence interval; IV, inverse variance; SD, standard deviation; Std,
standardized. [Correction added on 9 July 2018, after first online publication: Figure 2 was incorrect and has been replaced in this version.]

334 ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
 Psychological therapy for menopausal symptoms

Table 1. Table of study characteristics

Study Population Intervention Type, Comparison Outcomes measured

author, year, study largest N analysed, Group or individual, concept, scale
design, country population type, mean program length, population
age tailored or general

Mindfulness-based intervention
Bower et al., (2015)19 65, BC survivors MAP, Group WLC F/NS severity
RCT Mean age: 47 6 9 2 h, weekly
Tailored
Hoffman et al., (2012)28 214, BC survivors MBSR, Group WCL Menopausal symptoms
RCT Mean age: 50 8 9 2 h, weekly + 2 h
General
Carmody et al., (2011)30 92, peri/post-menopausal MBSR, Group WCL HF bother
RCT Mean age: 53 8 9 2.5 h, weekly HF intensity
General Menopausal symptoms
Cognitive behavioural therapy-based interventions
Duijts et al., (2012)17 173, BC survivors CBT, Group WLC Menopausal symptoms
RCT Mean age: 48 6 9 1.5 h, weekly HF/NS bother
Tailored sex. freq. change
Ayers et al., (2012)18 129, peri/post- CBT, Group WLC HF/NS problem rating
RCT menopausal 4 9 2 h, weekly Tailored HF/NS frequency
mean age: 53
Mann et al., (2012)29 88, BC survivors CBT, Group CAU (BCFU) HF/NS problem rating
RCT mean age: 54 6 9 1.5 h, weekly HF/NS frequency
Tailored
Keefer et al., (2005)31 19, perimenopausal CBT, Group WLC HF frequency/2 weeks
RCT Mean age: 51 8 9 1.5 h, weekly HF/NS problem rating
Tailored
Hunter et al., (1996)32 RCT 24, menopausal Mean CBT, Individual WLC HF/NS problem rating
age: 52 4 9 1 h/6–8 weeks HF/NS frequency
Tailored
Behavioural therapy-based interventions
Lindh-Ȧstrand et al., 59, post-menopausal BT, Group WLC HF frequency/24 h
(2013)20 Mean age 54.9 10 9 1 h/12 weeks VM symptoms and sexual
RCT Tailored behaviour
Fenlon et al., (2008)27 104, BC survivors BT, individual Att. C HF frequency/week
RCT Median age: 55 191h HF severity
General HF/NS problem rating
Menopausal symptoms
Fenlon et al., (1999)26 16, BC survivors BT, Individual WLC HF frequency/24 h
RCT Mean age: 48 2 weekly. HF/NS problem rating
General
Irvin et al., (1996)33 33, post-menopausal BT, Individual Act. C HF frequency/24 h
RCT Mean age 50.8 191h HF intensity
General

Act. C, active control group; Att. C, attention control group; BC, breast cancer; BT, behavioural therapy (relaxation); CAU, care as usual; CBT,
cognitive behavioural therapy; HF, hot flush; MAP, mindfulness awareness programme; MBSR, mindfulness-based stress reduction; NS, night
sweats; VM, vasomotor.

found in the meta-analysis. Hot flush frequency however,

Discussion
Main findings
A small to moderate reduction of short- and medium-term
hot flush bother and short-term menopausal symptoms by
psychological interventions (i.e. CBT, BT and MBT) was
was not statistically significantly reduced by psychological
interventions. Furthermore, the short- and medium-term
hot flush bother was reduced by psychological interventions
in the breast cancer survivor subgroup and the natural
menopause subgroup. However, medium-term hot flush

ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of 335
Royal College of Obstetricians and Gynaecologists
 van Driel et al.
Table 2. Meta-analysis for hot flush frequency, hot flush bother and menopausal symptoms (short- and medium-term)
Outcome No. of studies N total
Short-term (<20 weeks)
HF frequency 6 300
HF bother 7 568
Menopausal symptoms 3 474
Medium-term (≥20 weeks)
HF frequency 3 234
HF bother 5 486
Menopausal symptoms 2 264
HF, hot flushes.
*Statistically significant (<0.05).
**Low: 0–24%, moderate: 25–49%, substantial: 50–74%, significant 75–100%.22
[Correction added on 9 July 2018, after first online publication: In table 1, the data for HF bother for short-term (<20 weeks) and medium-term
(≥ 20 weeks) have been corrected.]
bother reduction was bordering on statistical significance in
the breast cancer survivor subgroup. No adverse effects
caused by psychological interventions were reported.
Strengths and limitations
This systematic literature review and meta-analysis is the first
to investigate and quantify the efficacy of CBT, BT and MBT
on menopausal symptoms in both naturally occurring and
treatment-induced menopause in survivors of breast cancer
with inclusion of recently published studies and novel mind-
fulness interventions. Furthermore, a large number of RCTs
were included and subgroup analyses were possible for natu-
ral and treatment-induced subgroups for most outcomes. An
important aspect of this systematic literature review and
meta-analysis is that only patient-reported outcomes were
included, which reflect the actual inconvenience caused by
hot flushes.23 A high level of heterogeneity was found in the
meta-analysis, probably because of the differences in popula-
tions (natural versus treatment-induced) and possibly due to
differences between interventions (e.g. type, duration). The
level of heterogeneity was not of great concern because the
aim of this systematic literature review and meta-analysis
was to answer the wider question about the effectiveness of
psychological interventions as a whole, as they are all based
on the similar principal of stressor impact reduction, in all
menopausal women regardless of cause. Other limitations
were the fact that some of the included RCTs were small (i.e.
five of the twelve studies consisted of <60 participants in
total) and possible presence of publication bias.
Interpretation
Hot flush bother versus hot flush frequency
As reduction of hot flush bother was greater than the
reduction of hot flush frequency it could be that the main
336 ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
SMD (95% CI) P (overall effect) I2 **/chi-square/P (heterogeneity)
0.41 ( 0.83 to 0.01) 0.05 65%/14.19/0.01
0.54 ( 0.74 to 0.35) <0.001* 18%/8.49/0.29
0.34 ( 0.52 to 0.15) <0.001* 0%/1.46/0.48
0.31 ( 0.89 to 0.26) 0.29 79%/9.55/0.008
0.38 ( 0.58 to 0.18) <0.001* 16%/4.79/0.31
0.45 ( 1.07 to 0.18) 0.16 83%/5.82/0.02
mechanism of action of psychological interventions is to
modify cognitive appraisal of hot flushes, thereby increas-
ing coping skills to reduce the impact of hot flushes.13 In
the general population, women who report a low frequency
of hot flushes can still experience substantial bother by hot
flushes and vice versa.34 Frequency of hot flushes has been
identified as being associated with bother by hot flushes.34
However, they were not interchangeable as other factors
such as affect, symptom sensitivity, general health and sleep
problems are also associated with the level of bother by hot
flushes.34 So, reduction of bother by hot flushes might be
the most appropriate measure of improved quality of life
in women suffering from vasomotor symptoms.34,35
Effectiveness in breast cancer survivors
Psychological interventions could be a valid strategy to
reduce hot flush bother in breast cancer survivors. This is
an important finding of the meta-analysis as breast cancer
survivors are contraindicated to use HRT, but report more
frequent, more severe, more distressing and a longer dura-
tion of hot flushes compared with age-matched controls or
naturally menopausal women.6,36–38
Lack of long-term outcomes
No studies reported on long-term (≥52 weeks) outcomes.
The effect of a booster session on maintaining the effect of
the intervention warrants further investigation. This could
not be evaluated properly in the meta-analysis because only
two studies incorporated a booster session and did so
within the short-term period.17,27
Lack of sexual outcomes
Only two of the 12 included studies reported on sexual
outcomes.17,20 The lack of sexual outcomes in current
research stands in stark contrast to the fact that sexual
Royal College of Obstetricians and Gynaecologists

functioning is shown to be severely impaired during meno-
pause with 76% of menopausal women reporting sexual
dysfunction.5,39–41 A recent one-armed pilot study aimed at
improving sexual functioning in women with surgical
menopause investigated the effect of an intervention com-
bining MBT and sexual health education and found statisti-
cally significant improvement of sexual functioning.42 This
suggest that psychological therapy could be an effective
intervention for improving sexual functioning in meno-
pause. Indeed, a review by Al-Azzawi et al. concludes that
nonpharmacological approaches, including psychological
therapy, should be the first step in treating postmenopausal
sexual dysfunction, before moving on to pharmacological
options.43
Other causes of treatment-induced menopause
Lastly, breast cancer treatment was the only cause for treat-
ment-induced menopause that was investigated in the
included studies. However, there are more causes for treat-
ment-induced menopause such as risk-reducing salpingo-
oophorectomy in women with high risk for ovarian cancer
(e.g. BRCA1/2 mutation carriers). Risk-reducing salpingo-
oophorectomy in BRCA1/2 mutation carriers has become a
widely applied procedure causing early surgical
menopause.44–47 Next to an increased risk for developing
ovarian cancer, BRCA1/2 mutation carriers also have an
increased risk of developing breast cancer.48–52 About one-
third of BRCA1/2 mutation carriers who experience surgical
menopause have had breast cancer and therefore have a
contraindication for using HRT.53 This signifies the need
for a safe, nonhormonal alternative for alleviating meno-
pausal symptoms in groups with different causes of treat-
ment-induced menopause.
Conclusion
The need for nonhormonal alternatives to HRT has been
firmly established following the publication of the Women’
Health Initiative10 and considering the contraindication of
HRT in breast cancer survivors. The results of this review
suggest that psychological interventions could be a safe and
effective treatment that reduces bother by hot flushes in all
women experiencing symptoms associated with menopause,
including breast cancer survivors. These findings support
healthcare providers in offering psychological interventions
to women who suffer from hot flushes and menopausal
complaints, especially for women who will not be using
HRT.
However, larger trials with a longer follow-up time are
needed to confirm the (long-term) effectiveness of psycho-
logical therapies. Furthermore, RCTs investigating the
ª 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Psychological therapy for menopausal symptoms
comparative effectiveness of CBT, BT and MBT are needed,
as studies on this topic are scarce.
The staggering lack of sexual outcomes in current
research in conjunction with the fact that sexual function-
ing is severely impacted during menopause, emphasises that
future research should focus on the effect of psychological
interventions on sexual outcomes.
Disclosure of interests
None declared. Completed disclosure of interests form
available to view online as supporting information.
Contribution to authorship
All authors (CvD, AS, MS, MM and GdB) were involved in
the design and execution of the trial, analysis of the data
and writing of the paper. CvD and AS contributed equally
as first authors of the manuscript.
Details of ethics approval
For this study, no approval was required from a medical ethics
committee as no experiments were done on human beings.
Funding
No funding was provided for this research.
Acknowledgements
No additional acknowledgements.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Figure S1. Funnel plots for short and medium term hot
flush frequency, hot flush bother and menopausal symp-
toms including Egger test results.
Figure S2. Forest plot of short-term hot flush bother
(subgroups natural versus treatment-induced menopausal
symptoms).
Table S1. Search terms.
Table S2. Domains and scoring of Cochrane risk of bias
tool22
Table S3. Outcomes and results per outcome type.
Table S4. Risk of bias assessment as measured with the
risk of bias tool from the Cochrane collaboration.
Table S5. Transformed outcomes and results per out-
come type as used in the meta-analysis. &
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